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League of Minnesota Cities Insurance Trust <br />Group Self-Insured Workers' Compensation Plan <br />Administrator <br />Berkley Administrators <br />Member of the W. R. Berkley Group r\ C P <br />PO Box 59143 Minneapolis, MN 55459-0143 Phone (612) 544-0311-^^^2 > 1996 <br />NOTICE OF PREMIUM OPTIONS <br />FOR STANDARD PREMIUMS OF 525.000 — $40.000 <br />The "Cit/ <br />ORONG <br />Agreement N04 <br />Agreement Period: ■-*^"'•'’-’'•'36=!“ i E <br />From: <br />To:01/01/1997 <br />01/01/1993P 0 BOX 66 <br />CRYSTAL BAY MH 553E3-0000 <br />Enclosed is a quotation for workers’ compensation deposit premium. Deductible options are now available in return <br />for a premium credit applied to your estimated standard premium of . The deductible will apply <br />per occurrence to paid medical costs only. There is no aggregate lindr.’^**'"'' <br />As an alternative, cities with a standard premium in excess of S25,000 may select from several retro-rated premium <br />options. The final net cost under the retro-rated option equals the audited standard premium times the minimum <br />factor plus losses and all loss-related costs, not to exceed the audited standard premium times the maximum factor. <br />The net cost for each retro option based on your esiiniated payroll, would be between the mirumum and maximum <br />amounts shown below, depending upon y$>ur losses. Adjustments will be made apprarJmately $i.\ months after the <br />close of your agreement year and annually thereafter until all claims arc closed. These adjustments will b« based <br />on audited payroll amounts and reserved as well as paid losses. <br />Please indicate below the premium option you wish to select. You may choose only one, and you cannot change <br />options during the agreement period. <br />OPTIONS <br />1 ^ Regular Premium Option <br />Deductible Options: <br />Retrospectively Rated Premium Options: <br />Retro-Rated Est. Minimum <br />Minimum Factor Premium <br />8 □ 85.4% <br />9 n 79.4% 25hE1. <br />10 □ 68.8% 230E7. <br />Maximum <br />Factor <br />115% <br />125% <br />150% <br />NET DEPOSIT PREMIUM <br />E9743. <br />Deductible Premium Credit <br />per Occurrence Credit Amount <br />2 □S250 3%970.£3773. <br />3 □500 4.5%i-f55.E8S83. <br />4 □1,000 6%1940.S7803. <br />5 □2,500 10%3E34.S6509. <br />6 □5.000 13.5%4366.E5377. <br />7 □10,000 18%55E1.E39ES . <br />Est. Maximum (See#l above <br />Premium for net deposit <br />doaiv. premium) <br />hOOEI. <br />43';>£'i. <br />This should be signed by an authorized representative of the city requesting coverage.One of the above options must <br />be selected. Please return a signed copy of this notice to the Administrator with payment and make checks payable <br />to the LMCIT. <br />Signature Title ' Date <br />For more information on the premium options that apply to your city, refer to the enclosed brochures. <br />BA 4502(12/96) <br />3^e